Incompetence within the public health sector is widespread and government has so far lacked the political will and leadership to manage underperformance, rewarding loyalty rather than the ability to deliver.

This is one of the conclusions reached by Professor Jerry Coovadia, Victor Diatz Professor of HIV/AIDS Research at the University of KwaZulu-Natal in Durban, writing for The Lancet in an exclusive series on health care in South Africa.

Released in late August, the comprehensive Lancet series on South Africa's health sector documents the enormous health battles this nation is facing on several fronts, tracing their historical routes and recommending priorities for the future.

Coovadia, an internationally respected academic and clinician, says poor leadership and stewardship 'run like a ruinous cancer' through the public health system. Inexperienced managers in positions of seniority were struggling to deal with major challenges, particularly human resource management.

He warned that without concerted efforts to 'change national thinking on accountability', South Africa would become a country that was not just a product of its past, but one that was continually unable to address current health problems or prepare for the future. 'There is no personal accountability.

Leaders and managers have not been held accountable when mistakes have been made.'

Former President Mbeki's 'bizarre and seemingly unshakeable belief that HIV did not cause AIDS' resulted in hundreds of thousands of lives lost and a substantial burden of ill health.

Weak management killing good policies

Coovadia said that while the public health system had been transformed into an integrated, comprehensive national service, failures in leadership and stewardship and weak management led to inadequate implementation of often good policies. Pivotal facets of primary health care were still not in place, with the HIV epidemic contributing to and accelerating challenges.

Thanks to the ill-conceived decision to close a number of nursing colleges to save money during former President Thabo Mbeki's era, and migration, the rate of skilled professional nurses had dropped from 149 per 100 000 in 1998 to 110 per 100 000 in 2007.

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As many as 40% of nurses were due to retire in 5 - 10 years and nursing remained the most crucial area for urgent policy intervention.

Highlighted in The Lancet's feature is the country's 'cocktail' of epidemics: HIV/AIDS, tuberculosis, poor maternal and child health and increasing chronic diseases.

HIV, TB and interpersonal violence were among the worst in the world, a paper by local researchers, Mohamed Seedat, Ashley van Niekerk, Rachel Jewkes, Shahnaaz Suffla and Kopano Ratele, said.

World leaders in violence

The overall injury death rate of 157.8 per 100 000 population was nearly twice the global average, while the death rate of women killed by their intimate partners was six times the world norm.

Some 3.5 million people sought health care for injuries, half of which were caused by violence. Most affected were young men aged 15 - 29, both as victims and perpetrators, with seven times more men than women dying in homicides.

Alcohol featured in most violent attacks while child homicides were double those of other low-income countries, with boys aged 10 - 14 most in danger of being killed. More than 40% of men admitted to being physically violent towards their partners and 88% of Soweto women reported physical or psychological abuse by partners.

While the murder rate had been reduced, the same was not true for the rape rate, where a random population-based sample found that over a quarter of men (27.6%) admitted to having committed rape. Most first raped before the age of 20 and half of these would rape again. Up to 14% of men admitted to taking part in gang rape.

Almost 4 in 10 girls reported experiencing sexual violence before the age of 18, with most of this unreported. In Gauteng in 2003, 1 in 35 reported rape cases involved victims aged between 1 and 3 years old, while 40% were under 18.

The authors noted that income inequality, low economic development and high levels of gender inequality were strong positive predictors of rates of violence and injury.

Supportive social dynamics included widespread poverty, joblessness, patriarchal notions of masculinity that 'valourised' toughness, risk taking and 'defence of honour'. Exposure to abuse in childhood, weak parenting, access to firearms, widespread alcohol misuse and weakness in law enforcement also supported violence.

The authors noted that during apartheid there was very little common-law policing, particularly in historically black areas, and some property crimes were justified as 'redistribution of wealth'. 'People resisted abiding by laws ... consequently lines between criminal and community blurred and an ambiguity about enforcement emerged,' they added.

Improve neonatal care and PMCT coverage

In a paper on the alarming maternal and infant morbidity and mortality rates, Dr Mickey Chopra and colleagues from the South African Medical Research Council estimate that 11 500 infant lives could be saved by effective implementation of basic neonatal care at 95% coverage.

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Similar coverage of dual therapy prevention of mother-tochild transmission with appropriate feeding choices could save 37 200 children's lives annually in 2015 compared with 2008. These interventions could also avert many maternal deaths and stillbirths. Such a target package would cost an estimated 24% of the public sector health expenditure and put South Africa squarely on track to meet the Millennium Development Goals.

They said the costs were affordable but the 'key gap' was leadership and effective implementation at every level of the health system, including national and local accountability for service provision.

The first would be to establish a dedicated and strengthened health workforce for the public sector, then ensuring health for all through an affordable national health insurance system and, finally, giving leadership and managerial positions to those who were 'most competent and not afraid of being held accountable'.